Get Radiology Imaging Request Form

Completing the Radiology Imaging Request Form online is a straightforward process that ensures you provide all necessary details for your imaging needs. This guide offers detailed instructions to help you fill out each section accurately and efficiently.

Follow the steps to complete the Radiology Imaging Request Form.

1. Click ‘Get Form’ button to access the Radiology Imaging Request Form and open it in your preferred editing interface.
2. Indicate the urgency of the imaging request by selecting one of the options: routine, emergent, or sedated MRI. Provide the date of the request.
3. Fill in the patient's personal information, including their name, date of birth, and phone number. Include additional details such as the patient's height and weight.
4. Specify if the patient will hand carry the imaging disk (CD), and provide the last menstrual period (LMP) date if relevant.
5. Clearly state the imaging requested, providing descriptions for each type of imaging. Include detailed information about the diagnosis codes (ICD) and relevant history or symptoms.
6. Complete the ordering provider's information, including their first and last name, title, clinic name, contact information, and tax ID number.
7. If applicable, provide an emergency contact number for urgent results and a daytime number for further communications.
8. If the results need to be sent to someone other than the ordering provider, fill out their details, including name, clinic/specialty, phone, and fax numbers.
9. Indicate whether the patient is scheduled for the imaging and provide the location and date if they are.
10. Review the entire form for completeness and legibility. Ensure all critical fields are filled in to prevent delays.
11. Once satisfied with the information provided, save changes, download, print, or share the form as needed.

Start accessing and completing your Radiology Imaging Request Form online today to ensure timely and accurate imaging services.